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Referrer: Date: Road Traffic Accident: Driver/Passenger/Pede Strian

This document collects information about a potential client involved in a road traffic accident, including their contact details, details of the accident itself including date/time/location, who was at fault, injuries sustained, and whether they have received any previous legal advice or compensation. Witness information and insurance details for all parties are also requested.

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Bhuwan Gupta
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© Attribution Non-Commercial (BY-NC)
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61 views

Referrer: Date: Road Traffic Accident: Driver/Passenger/Pede Strian

This document collects information about a potential client involved in a road traffic accident, including their contact details, details of the accident itself including date/time/location, who was at fault, injuries sustained, and whether they have received any previous legal advice or compensation. Witness information and insurance details for all parties are also requested.

Uploaded by

Bhuwan Gupta
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Referrer: Date:

Client full name:

Road Traffic Accident


Telephone Home : Work : Mobile : Best Time to call: Date of Birth: Marital Status: Occupation: Nationality: Email Address: National Insurance No:

Driver/Passenger/Pede strian

Address:

Have you instructed any other solicitor or signed any paperwork for injuries compensation before:

Litigation Friend(if customer is not able to speak due to any reason)Name, Address & Contact Number: Date of RTA: Time of RTA: Names: Location of RTA: Age & Date of birth: Position in Vehicle: Were police involved (If so PC No / Police Station) If Yes, Police Report Ref No: Were there any witnesses (if yes please
provide name and addresses)

Description of Accident :

Passengers Details: (If any)

Who is to Blame : (Who paid the car damages? Customers insurance company or T.P insurance company)

Driver
Name & address: Make & Model of vehicle: Registration: Insurance Details
Insurance company name:

3rd Party
Name & Address: Make & Model of Vehicle: Registration: Insurance Details
Insurance company name:

Witness 1 : Witness 2: Were you wearing a seat belt :Yes/No What injuries did you sustain: Have you had any other relevant injuries to those suffered in the accident: Are you fully recovered from accident:

Policy Number: Have you had any time off work: Have you suffered with loss of earnings (if so how much) Have you incurred any out of pocket expenses as a result of the accident: Are there any sports or hobbies affected due to accident:

Policy Number: Hospital attended:

GP Name & Address: No. of Visits:

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